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Maze Procedure
 
Basic Facts
The Maze procedure is a surgical treatment for atrial fibrillation.
In the Maze procedure, the physician uses small incisions or an energy source to create scar tissue that blocks the abnormal electric signals associated with atrial fibrillation.
The Maze procedure has been found to safely and effectively eliminate atrial fibrillation and decrease the risk of stroke in the majority of patients.
The Maze procedure is a treatment for atrial fibrillation. In the Maze procedure, the physician uses small incisions or an energy source to create scar tissue. The scar tissue, which does not conduct electrical activity, blocks the abnormal electrical signals causing the arrhythmia.

The Maze procedure has several variations:
  • Cox-Maze III, an open-heart surgery, which requires the surgeon to make incisions in the atria in an intricate pattern resembling a maze. The surgeon immediately sutures (sews) these incisions, and scar tissue forms as they heal;
  • Cox-Maze IV (surgical ablation), which is an open-chest procedure, however, instead of creating incisions in the heart tissue, the physician uses radiofrequency, cold (cryo), ultrasound, or microwave energy to create the scar tissue; and
  • Mini Maze or thoracoscopic Maze, in which the physician inserts thin surgical tools and fiber-optic cameras into small incisions in the chest, then uses energy-based techniques to create the scar tissue.
WHEN IS IT INDICATED?

The Maze procedure is indicated when:
  • Medication does not control atrial fibrillation;
  • Patients do not tolerate AF medications, such as the anticoagulant warfarin (trade name Coumadin); and
  • The patient has experienced a stroke.
PRE-PROCEDURE GUIDELINES

Tests the physician may order include:
  • Chest x ray;
  • Blood and urine tests;
  • Stress test;
  • Electrocardiography, or ECG; and
  • Echocardiography.
WHO IS ELIGIBLE?

Patients are eligible for the Maze procedure if they:
  • Are between 18 and 80 years of age;
  • Have atrial fibrillation that causes symptoms;
  • Have unsuccessfully tried antiarrhythmic drugs or cannot tolerate them;
  • Cannot take warfarin;
  • Have not had previous open-chest surgery; and
  • Have undergone ablation that failed or who are not candidates for ablation.
Patients would be eligible for open-heart Maze surgery if they met the above criteria and required some other form of heart surgery, such as CABG, or valve repair or replacement surgery.

WHAT TO EXPECT

Cox-Maze III and IV
The patient is given anesthesia through an intravenous (IV) line in the arm, which induces sleep and eases pain. To begin the operation, the surgeon makes an incision, called a sternotomy, through the breastbone to open the chest and ribcage and access the heart. Once the chest is open and the surgeon accesses the heart and the aorta, the heart is stilled and the patient is connected to a heart-lung machine, which stops blood from circulating through the coronary arteries when the surgeon is working on the heart itself.

The surgeon places, and then sutures, incisions in both atria or uses an energy source to prevent the abnormal electrical signals from traveling through the atria. The surgeon will remove the left atrial appendage.

Open surgery takes 2 to 4 hours to complete.

Minimally invasive Maze

The surgeon makes three or four small incisions between the patient's ribs either on the left side of the body or on both sides of the body, to gain access to the heart. The surgeon then inserts a thorascope (endoscope) and an ablation device into the other incisions. He or she uses an energy-tipped probe to create the scar tissue and remove the left atrial appendage. The procedure takes 2 to 4 hours to complete.

POST-PROCEDURE GUIDELINES

Patients may be discharged from the hospital within 5 to 7 days. The physician will provide specific instructions to patients regarding bathing, wound care, medications, and activity levels, including returning to work. Full recovery may take 6 to 8 weeks for open-heart procedures; less time will be required for minimally invasive versions.

Patients may continue to experience episodes of arrhythmia for the first few months following Maze, which should subside over time.

POSSIBLE COMPLICATIONS

The risks of the Maze procedure are similar to the risks of any heart surgery and include:
  • Bleeding;
  • Infection;
  • Kidney dysfunction or failure;
  • Stroke;
  • Pneumonia;
  • Heart attack;
  • Heart block;
  • New arrhythmias; and
  • Death.
Occasionally, other arrhythmias that were masked by the AF may be uncovered following the Maze procedure, which requires implantation of a pacemaker.
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